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© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. Background: Antibiotic over prescription for upper respiratory tract infections (URTIs) in primary care exacerbates antimicrobial resistance. There is a need for effective alternatives to antibiotic prescribing. Honey is a lay remedy for URTIs, and has an emerging evidence base for its use. Honey has antimicrobial properties, and guidelines recommended honey for acute cough in children. Objectives: To evaluate the effectiveness of honey for symptomatic relief in URTIs. Methods: A systematic review and meta-analysis. We searched Pubmed, Embase, Web of Science, AMED, Cab abstracts, Cochrane Library, LILACS, and CINAHL with a combination of keywords and MeSH terms. Results: We identified 1345 unique records, and 14 studies were included. Overall risk of bias was moderate. Compared with usual care, honey improved combined symptom score (three studies, mean difference-3.96, 95% CI-5.42 to-2.51, I2=0%), cough frequency (eight studies, standardised mean difference (SMD)-0.36, 95% CI-0.50 to-0.21, I2=0%) and cough severity (five studies, SMD-0.44, 95% CI-0.64 to-0.25, I2=20%). We combined two studies comparing honey with placebo for relieving combined symptoms (SMD-0.63, 95% CI-1.44 to 0.18, I2=91%). Conclusions: Honey was superior to usual care for the improvement of symptoms of upper respiratory tract infections. It provides a widely available and cheap alternative to antibiotics. Honey could help efforts to slow the spread of antimicrobial resistance, but further high quality, placebo controlled trials are needed. PROSPERO registration No: Study ID, CRD42017067582 on PROSPERO: International prospective register of systematic reviews (

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BMJ Evidence-Based Medicine

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